Board Review

A 39-year-old man in hospice is evaluated for depressed mood. He has progressive amyotrophic lateral sclerosis, with an estimated life expectancy of weeks to months. His wife is his primary caregiver, and he has two teenage sons still at home. The patient is tearful and reports feeling sad and overwhelmed at times. He is fatigued, his appetite is poor, and he has lost weight. He admits to sometimes wishing death would come quickly but has no plan to act on these feelings. He attributes his illness to past illicit drug use and feels guilty that his sons will come of age without their father.

Which of the following is the most likely diagnosis?

A) Adjustment disorder with depressed mood

B) Anticipatory grief

C) Major depression

D) Persistent complex bereavement disorder

Answer: C - Major depression

Objective: Diagnose depression in the setting of terminal illness.

Key Point

In a terminally ill patient, feelings of guilt, hopelessness, helplessness, and worthlessness may distinguish depression from anticipatory grief.

This patient's sense of guilt is indicative of pathologic depression. Although anticipatory grief may be common at the end of life, depression is never normal in dying patients. However, it can be very challenging to differentiate normal grief from depression in terminally ill patients. Validated depression screening tools, such as the PHQ-9, rely heavily on the presence of symptoms associated with functions necessary to maintain life (historically termed vegetative symptoms) such as changes in appetite, sleep, and energy level, which are common and expected in patients with advanced illness. This makes these instruments more difficult to interpret when assessing for depression. Many patients with terminal illness, such as this one, verbalize thoughts of death or express a desire for hastened death. Persistent, pervasive thoughts of suicide, which are not seen in this patient, are not normal and should be addressed promptly and aggressively when present. Guilt or self-blame is unique to depression and not seen in normal grief. Other symptoms unique to depression include hopelessness, helplessness, and worthlessness. When differentiating depression from grief, it is important to assess for these symptoms, as depression is highly treatable even in terminally ill patients.

Adjustment disorder with depressed mood occurs in patients who do not meet the criteria for major depression but have a depressed mood. Symptoms begin within 3 months of a stressful event and do not last longer than 6 months. This patient's guilt is indicative of depression, not an adjustment disorder.

Anticipatory grief occurs in patients and loved ones as they mourn the many losses leading up to an expected death. Such grief is waxing and waning in nature, with periods of sadness interspersed with periods of joy.

Grieving that lasts for more than 12 months (6 months in children); is associated with persistent yearning, sorrow, or preoccupation with the deceased; disrupts normal function or social relationships; and is out of proportion to cultural norms is considered pathologic and is termed persistent complex bereavement disorder, formerly complicated grief disorder. Persistent complex bereavement disorder occurs in loved ones after a death, not in the patient who is dying.

Swetz KM, Kamal AH. In the clinic. Palliative care. . 2012 Feb 7;156(3):ITC2-1-TC2-16. Link Out